19. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any indications that something has gone wrong. The reasons for our decision are set out below.
Discharge from hospital:
20. Mr A says his wife was not fit enough to be discharged from hospital on 19 June and the Trust should have waited to discharge her until after the outcome of the multidisciplinary team (MDT) meeting on 21 June. He says when they got home, his wife was so weak she could barely walk to the front door with the aid of a frame, and she had to continue to sleep on a recliner chair as could not manage to walk to the stairlift to get upstairs.
21. The Trust say Mrs A’s condition improved on 14 June, which meant discharge planning could commence and there was no reason for her to stay in hospital after chest drain was removed on 17 June.
22. The Department of Health Hospital Discharge Service policy lists the criteria for a patient to stay in hospital. If a patient does not meet any of these criteria, they should be considered for discharge. The criteria is as follows:
•requiring intensive therapy unit (ITU) or high dependency unit (HDU) care •requiring oxygen therapy/non- invasive ventilation (NIV) •requiring intravenous fluids •NEWS score greater than 3? (clinical judgement required in persons with atrial fibrillation and/or chronic respiratory disease) •diminished level of consciousness where recovery realistic •acute functional impairment in excess of home/community care provision •last hours of life •requiring intravenous medication (including analgesia) •undergone lower limb surgery within 48 hours •undergone thorax-abdominal or pelvic surgery with 72 hours •within 24 hours of an invasive procedure (with attendant risk of acute life- threatening deterioration)
23. The treating doctor noted during the ward round on 19 June Mrs A ‘felt okay’ and was keen to go home. The national early warning score (NEWS) is a tool used to detect and respond to clinical deterioration. Mrs A’s NEWS calculated from the written physiological observations was two, which indicates the clinical risk is low.
24. Mrs A’s blood tests had also significantly improved. The notes say Mrs A had walked around her bedspace and a stairlift was due to be installed at home. Our physician adviser says Mrs A did not meet any of the criteria set out in the NHS guidelines above. There was therefore no reason for her to stay in hospital on 19 June, and it was appropriate for the Trust to discharge her.
25. We appreciate Mr A’s strength of feeling about this, and we are very sorry to hear about his concerns around his wife’s discharge from hospital. Mrs A had expressed a wish to be at home and she had capacity to make this decision. She had advanced cancer with a poor prognosis, and she was very sadly always at risk of deterioration which our physician adviser says would not have been prevented by a longer hospital admission. We consider the Trust acted in line with guidance and there is no indication something has gone wrong here.
Care and support package:
26. Mr A says the Trust discharged his wife without putting a care and support package in place. The Trust say Mr A indicated a preference to assist with personal care and therefore no package of care was arranged on discharge. It says all equipment that was essential at the time of assessment and discharge was in place, all onward referrals were made for urgent therapy follow ups, and useful contact numbers were provided.
27. The Department of Health hospital discharge guidance says patients being discharged from hospital can be categorized into four pathways:
Pathway zero
• simple discharge home • no new or additional support is required to get the person home, or such support constitutes only: • informal input from support agencies • a continuation of an existing health or social care support package that remained active while the person was in hospital
Pathway one
The patient is able to return home with new, additional or a restarted package of support from health and/or social care. This includes people requiring intensive support or 24-hour care at home.
28. Pathway two is for discharge to a community hospital for patients requiring intensive support on a short-term basis and pathway three is for patients with long term needs who will be discharged to a care home. From the notes it appears the Trust categorised Mrs A as a pathway zero and therefore did not arrange any community support or a care package.
29. When the physiotherapist and occupational therapist assessed Mrs A on 16 June, they deemed she required assistance of one person for all activities, including standing up from the chair. Our nursing adviser says this infers she did require additional health/ or social care support in the community, which would mean pathway one would have been more appropriate for her. If the Trust had discharged Mrs A under pathway one, she would have been provided with home based intermediate care for a short time to assess whether she did need a care package.
30. Whilst there are indications Mrs A may have been eligible for some form of care package in the community based on her condition, the notes show she was keen to get home and both her and Mr A said they could manage at home without assistance. We are very sorry to hear about the difficulties they experienced after Mrs A arrived home and appreciate this was a very distressing time. Our nursing adviser says as Mrs A had capacity it was ultimately her decision whether she wanted a package of care, and this had to be respected by the medical teams. We do not consider there is any indication of a failing.
Communication about needs:
31. Mr A says the Trust did not make it clear the level of care and assistance his wife would need at home. The Trust say it would always be best practice to ensure relatives have a good level of understanding regarding the level of care required. It says both Mr and Mrs A were involved in discussions relating to discharge planning.
32. NICE Guidance (NG27) on transition between inpatient hospital settings and community or care home settings, highlights the importance of involving carers in the patients discharge. It says:
1.1.1 see everyone receiving care as an individual and an equal partner who can make choices about their own care. They should be treated with dignity and respect throughout their transition.
1.1.3 involve families and carers in discussions about the care being given or proposed if the person gives their consent. If there is doubt about the person's capacity to consent, the principles of the Mental Capacity Act must be followed.
1.5.29 The hospital and community based multidisciplinary teams should recognise the value of carers and families as an important source of knowledge about the person's life and needs.
1.5.30 With the person's agreement, include the family's and carer's views and wishes in discharge planning.
1.5.31 If the discharge plan involves support from family or carers, the hospital based multidisciplinary team should take account of their: •willingness and ability to provide support •circumstances, needs and aspirations •relationship with the person •need for respite
33. The notes show the plan was for Mrs A to stay within a micro- environment when discharged, so she would essentially stay in one or two areas of her home. The downstairs already had a reclining chair, and a commode was ordered. The therapists anticipated Mrs A would be able to use her new stair lift to get upstairs to bed. According to the documentation, this was discussed with Mr and Mrs A who were both happy with this plan.
34. On 15 June, the therapist had a telephone conversation with Mr A, where they highlighted Mrs A would require assistance with all personal care. The notes say Mr A said he was happy to do all the cooking and help his wife with washing and dressing. This discussion was reiterated at Mrs A’s bedside when Mr A came to visit, and the records say he was happy with the discharge plan.
35. Our nursing adviser says the therapy team communicated appropriately with Mr and Mrs A regarding what would happen when she was discharged from hospital, in line with NG27 above. The therapists noted they provided useful contact numbers to Mr and Mrs A if they needed help post discharge and referred Mrs A to the community palliative care team for review within seven days of discharge. We are very sorry to hear how Mrs A’s condition deteriorated after she was discharged from hospital, and we do not doubt this was a very stressful experience. We consider the Trust acted in line with guidelines and there is no indication of a failing.